A10. J6_Past Performance & Exp Questionnaire.pdf

Past Performance and Experience Questionnaire

Solicitation No. Project Title.

Contractor Name. UEI No.

2. Business Type:

☐ Company ☐ Co-partnership ☐ Corporation ☐ Individual ☐ Non-Profit Organization

3. How many years do you or your firm have in the line of work contemplated by this solicitation?

4. How many years of experience in contracting have you or your business had as a prime contractor ____ sub-contractor ____

5a. Are employees regularly on your payroll? ☐ Yes ☐ No 5b. No. of Employees 6a. Have you ever failed to complete any work awarded to you? ☐ Yes ☐ No 6b. If “Yes,” specify location(s) and reason(s) why.

1. Project Title Role: ☐ Prime ☐ Sub-contractor

Contract No. Total Contract Value ($) Period of Performance Dates From To

Description of Work (Provide a brief summary of the work performed.

(2–4 sentences))

Complete? ☐ Y ☐ N Percent Complete (if ongoing) %

RELEVANCE TO THIS REQUIREMENT Explain how this project is similar in scope, size, complexity, or customer type.

PERFORMANCE QUALITY (Contractor Self-Assessment) Rate your firm’s performance and provide explanation as applicable.

Area Rating Narrative (Option but encouraged)

Quality of Service ☐ Excellent ☐ Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory

Timeliness ☐ Excellent ☐ Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory

Customer Satisfaction ☐ Excellent ☐ Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory

Business Relations ☐ Excellent ☐ Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory

Customer Agency / Company:

POC Name: POC Telephone POC Email:

Solicitation No. Project Title

2. Project Title Role: ☐ Prime ☐ Sub-contractor

Contract No. Total Contract Value ($) Period of Performance Dates

From To

Description of Work (Provide a brief summary of the work performed.

(2–4 sentences))

Complete? ☐ Y ☐ N Percent Complete (if ongoing) %

RELEVANCE TO THIS REQUIREMENT Explain how this project is similar in scope, size, complexity, or customer type.

PERFORMANCE QUALITY (Contractor Self-Assessment) Rate your firm’s performance and provide explanation as applicable.

Area Rating Narrative (Option but encouraged)

Quality of Service

☐ Excellent ☐ Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory

Timeliness

Customer Satisfaction

Business Relations ☐ Excellent ☐ Good ☐ Satisfactory

3. Project Title Role: ☐ Prime ☐ Sub-contractor

RELEVANCE TO THIS REQUIREMENT Explain how this project is similar in scope, size, complexity, or customer type.

PERFORMANCE QUALITY (Contractor Self-Assessment) Rate your firm’s performance and provide explanation as applicable.

4. Project Title Role: ☐ Prime ☐ Sub-contractor

RELEVANCE TO THIS REQUIREMENT Explain how this project is similar in scope, size, complexity, or customer type.

PERFORMANCE QUALITY (Contractor Self-Assessment) Rate your firm’s performance and provide explanation as applicable.

5. Project Title Role: ☐ Prime ☐ Sub-contractor

RELEVANCE TO THIS REQUIREMENT Explain how this project is similar in scope, size, complexity, or customer type.

PERFORMANCE QUALITY (Contractor Self-Assessment) Rate your firm’s performance and provide explanation as applicable.

CERTIFICATION

I certify the information provided is accurate and the listed reference may be contacted for verification.

7a. AUTHORIZED REPRESENTATIVE NAME

7b. TITLE

7c. SIGNATURE (Sign in ink) 7d. DATE

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